Anesthesia Coding Alert

Hint: Use fourth and fifth digit expansion to specify complications.

Diabetes can lead to a range of potential complications when treating a patient from either a surgical or anesthesia standpoint. For example, having a higher BMI along with diabetes can make anesthesia administration more complicated. The patient’s diabetes (and level of severity) could also merit including physical status modifiers such as P2 (A patient with mild systemic disease) or P3 (A patient with severe systemic disease) on your anesthesia claim.

That’s why it’s always important to get as many details possible about the patient’s diabetes from the attending physician or surgeon prior to anesthesia administration – currently, and when ICD-10 goes into effect.

Focus on Type and Complication Under ICD-9

When a patient is diagnosed with diabetes mellitus or any manifestation of diabetes, you must determine the fourth digit for 250.xx (Diabetes mellitus) according to the type of diabetic complication the patient has, if any. If the patient presents with diabetes without any complications, your first four digits will be 250.0 (Diabetes mellitus without mention of complication).

Regardless of whether the patient has Type 1 diabetes or Type 2 diabetes, you’ll report the diagnosis with the same parent code, 250 (Diabetes mellitus). Under ICD-9, the fifth digit provides the final two pieces of information on the patient’s diabetic condition: the diabetes type (I or II) and whether it is controlled. Under ICD-9, the fifth digit options are:

• 0 – type II or unspecified type, not stated as uncontrolled
• 1 – type I (juvenile type), not stated as uncontrolled
• 2 – type II or unspecified type, uncontrolled
• 3 – type I (juvenile type), uncontrolled.

Caveat: Although you have different codes to report diabetes with complications, those codes are limited in their ability to specify the complications. For example, if a patient presents with Type 2 uncontrolled diabetes with the complication of proliferative diabetic retinopathy with macular edema, you’ll report the primary condition with 250.52 (Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled). As you can see in this example, from that code you can only make out that there is an ophthalmic complication without actually knowing what the manifestation is. To identify the particular manifestation, you will need to use one or more additional codes. Thus, in this example, you would also report 362.02 (Proliferative diabetic retinopathy) and 362.07 (Diabetic macular edema).

Check Complication Specifics for ICD-10

When your diagnosis coding system changes to ICD-10 in October 2014, you’ll no longer flip to the same code section for both Type 1 and Type 2 diabetes. Although you are currently accustomed to starting off with “250” for all diabetes patients, your coding options will expand dramatically under ICD-10. Under ICD-10, you’ll have to report Type 1 diabetes with E10.xxx and Type 2 diabetes with E11.xxx. The fourth digit specifies the organ systems that show some manifestation, for example, ophthalmic/neurologic/renal, and the fifth (and, sometimes, sixth) digit elaborates the type of complication.

Type 1: You’ll code all Type 1 patients by starting out with the E10 series (Type 1 diabetes mellitus), and then you’ll move on from there after reviewing the patient’s chart to determine whether any further manifestations exist.

Type 2: You’ll code all Type 2 patients by starting out with the E11 series (Type 2 diabetes mellitus), then moving on from there after reviewing the patient’s chart to determine whether any further manifestations exist.

Documentation: Just because Type I diabetes is often described as “juvenile type” or “juvenile onset,” don’t assume that all pediatric patients have Type I diabetes. It is becoming increasingly common for practitioners to diagnose and treat Type II diabetes developed in childhood or adolescence. Also, there are many instances when a physician might treat type 2 diabetes with insulin. So don’t automatically consider a patient who is being treated with insulin to be suffering from Type 1 diabetes.

Helpful in determining whether a patient has Type I or Type II diabetes is the results of a C-peptide assay, which measures insulin production and can indicate which type of diabetes is present. These test results may be important as you select your fifth digit under ICD-9, so check the documentation for those results.

Coder tips: When you prepare for ICD-10, adjust your superbills and electronic coding systems to offer the physicians the choice of Type 1 or Type 2 when they choose a diabetes diagnosis. Then leave a blank line marked “complication(s)” so that your provider can fill in any applicable complication, allowing you to select the most accurate code from among the many options available under ICD-10.